Dr John C Little MB BS Dr Jane E Harpur MB BS MRCGP€¦ · V6 Complete under 18’s registration...

V6 Complete under 18’s registration pack JDG Oct 16

Please ensure that you complete all of the following: (Please Tick)

Family doctor services registration form (GMS1) (Both Sides Please)

Patient Online:Registration Form (Access to GP Online Services) (Only if you require this) access)

Pre-registration form (under18) (Both Sides Please)

Under 18’s Registration

Pack


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Welcome

Our Mission Statement is: “We aim to provide high quality, easily accessible care in a family orientated

environment by a team of dedicated, well trained professionals”

The registration form (GMS1)

Full Name, Current Address and contact numbers (including your mobile number and email address) and Date of Birth

NHS number if possible (you should be able to find this on any documentation you have from your previous GP)

Your previous home address

Your previous GP and their address

All of the above will help us to ensure prompt receipt of your previous medical history.

You must provide the following documentation / Information:

For each adult over 18 in the household we require proof of your home address.

A utility bill, bank statement or tenancy agreement (stating the names of the adults at the property) is considered suitable proof of residency – driving licences are not accepted as proof of residency. (NB. These must not be dated more than 3 months ago)

A New Patient questionnaire is attached, please take the time to complete the details including next of kin, their contact details (email and mobile no’s) together with any relevant medical conditions.

New born children – Please ensure that you hand in the discharge letter from the hospital which has the birth and registration details of your new baby.

Your wishes regarding the sharing of your records with other authorised healthcare staff.

PLEASE ENSURE YOU SIGN IN THE THREE REQUIRED PLACES (first page of the NHS GMS 1 form, the Patient Online Registration form and the second page of the Pre-Registration form)


Other services

There is an online Practice Booklet available that explains more about the practice and services offered. http://www.practicebooklet.co.uk/mouls

The Practice offers online services for ordering regular repeat medication, booking and cancelling appointments and viewing your online summary care record. There is a leaflet enclosed explaining the services and a form to complete.

We also offer the electronic transfer of prescriptions. You should ask your local pharmacist to sign you up for this service.

If you are interested in sharing your views on how services are run, give constructive feedback and help shape the way the practice develops, why not join our Virtual Patient Participation Group by ticking the box on the attached online services registration form. There will be no need to attend meetings; we will contact you via email / SMS / Newsletters.

Please take advantage of our online services for repeat prescriptions and booking appointments. Our website has details of our opening times and the different services we provide.

Below and on the next page you will find some guidance as to which clinical member of staff may be best suited to deal with your medical problem. If you are in any doubt and would like some advice please feel free to ask at reception and we will do our best to point you in the right direction as many problems can be resolved by other clinical members of staff, rather than the Doctor.

Health Care Assistants

Healthcare assistants work closely alongside the Nurses and Drs in the Practice.

They can deal with: Blood tests Blood Pressure Checks Contraceptive Pill Check ECG (heart trace) Spirometry (breathing check) Injections (B12 & Flu) INR testing & dosing

NHS/New patient Healthchecks Stop Smoking advice Hearing tests Antenatal Booking paperwork Liefstyle Advice DressingsRemoval of Stitches

http://www.practicebooklet.co.uk/mouls


Practice Nurses Practice Nurses provide general nursing care along with Chronic Disease management & telephone triage. They can deal with: Telephone Triage for the GP’s Heart Disease Monitoring Asthma/COPD Monitoring Diabetes Monitoring Cervical Screening Immunisations (child & adult) Family Planning All Health Care Assistant jobs

General Practitioners (GP’s)

GP’s are highly skilled doctors who support patients throughout their lives. They help manage your health and aim to prevent chronic diseases. Many GP’s have special interests such as ENT, Dermatology and Gastroenterology so please ask at reception as to who may be the most appropriate for your condition. Some GP’s carry out practical procedures such as minor surgery


For Office Use Only Usual GP Dr Farah Dewan

Date Patient Informed Date Read Code Entered (Xab9D & XacWQ)

Date Online Access Granted Date Read Code Entered (Xabui)

Are Patient Signatures in place and is patient in area? Checked by:

Date:


Moulsham Lodge Surgery 158 Gloucester Avenue Chelmsford CM2 9LG

Dr A T Moulsham Lodge 5882


Patient Online: Registration form: Access to GP online services

I wish to have access to the following online services (tick all that apply): 1. Booking appointments

2. Requesting repeat prescriptions

3. Accessing my summary medical record

4. Virtual Patient Participation Group (Contact via email/sms/newsletters)

Application for online access to my summary medical record

I wish to access my summary medical record online and understand and agree with each statement (please tick)

1. I have read and understood the information leaflet provided by the practice

2. I will be responsible for the security of the information that I see or download

3. If I choose to share my information with anyone else, this is at my own risk

4. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

5. If I see information in my record that it not about me, or is inaccurate I will contact the practice as soon as possible

Print Name Relationship to patient (if signing on

behalf of a child)

Signature Date

For practice use only Identity verified through (tick all that apply)

Vouching Vouching with information in record

Photo ID

Verified by: Date

Name of person who authorised (if applicable)

Date

NHS number

Date account created

Date password given

Level of record access enabled Prospective Retrospective

All Limited parts

Contractual minimum

Surname First Name

Ethnic Origin (Tick all that are appropriate)

White Mixed Carribean Pakastani Other

Black British African Bengladeshi

Asian Irish Indian Chinese

Address & Postcode

Telephone Number Mobile Number

Date of birth Email Address


Patient Online: Records Access

Patient information leaflet ‘It’s your choice’ If you wish to, you can now use the internet to book appointments with a GP, request repeat prescriptions for any medications you take regularly and (from 31st March 2015) look at your summary medical record online. You can also still use the telephone or call in to the surgery for any of these services as well. It’s your choice. Being able to see your summary record online might help you to manage your medical conditions. It also means that you can even access it from anywhere in the UK should you require medical treatment. However, you cannot access your summary record online from outside of the UK. If you decide not to join or wish to withdraw, this is your choice and practice staff will continue to treat you in the same way as before. In general this decision will not affect the quality of your care. You will be given login details, so you will need to think of a password which is unique to you. This will ensure that only you are able to access your summary record – unless you choose to share your details with a family member or carer.

The practice has the right to remove online access to services for anyone that doesn’t use them responsibly.

It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your summary record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. If you can’t do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password. If you print out any information from your summary record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.

Things to Consider Choosing to share your information with someone It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure

Coercion If you think you may be pressured into revealing details from your patient record to someone against your will, it is best that you do not register for access at this time.


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Please complete the section below to help us identify any specific communication needs your child may have.

Does your child need information communicated to you in a specific format?

YES / NO

If yes, give details of the format that you need.................................................................

………………………………………………………………………………………………

……………………………………………………………………………………………….

Does your child need support when attending the surgery? YES / NO

If yes, please given details of the support you need.........................................................

………………………………………………………………………………………………

………………………………………………………………………………………………

……………………………………………………………………………………………….

Tell us today please speak to a member of reception.

For office use only : Enter Code Y4523 ………………… Initials …………………Date ……………………………….

Entered by: ………………………………… Date ……………………………….


PRE-REGISTRATION FORM (UNDER 18 YEARS OLD) (At least one parent and/or guardian to be registered at the Practice)

Details of Person filling in the form: What relationship do you have to the child (e.g. Parent, Step Parent, Guardian, Foster Carer):

First Name: Surname: Address:

Child’s Details

Surname:

First Name:

Date of Birth :

Sex: Male / Female

Address : (if different from above) Post Code :

Contact details Home Tel.: Mobile No:

Child’s first language:

Ethnicity:

Child’s country of birth:

If from overseas, when did the child enter the country:

Family Details:

Mothers full name: DOB:

Father’s full name: DOB:

Names and DOB of siblings:

Name and relationship to child of any other household members:

Address of mother/father* (if different from child’s) : *delete as appropriate

Name and address of most recent school or nursery:


Health Information

1. Does the child have any major illnesses, operations, chronic illnesses such as Asthma or any disabilities? Yes No

Please list with dates:

2. Any current or regular medication: Yes No If “yes” please list below:

3. Is your child allergic to anything? Yes No If “yes” please list below:

4. Immunisations – Please bring the child’s Red Box

Families Receiving Additional Support

1. Does your child have a social worker? Yes No

(If yes, please give their name, address and contact number)

2. Is the child in a care home or fostered? Yes No

Who has Parental Responsibility?

Online Access

If the child is aged between 16 and 18 they need to sign in this box to confirm that they give permission for you to access their online account for ordering prescriptions and making appointments 16-18 year old’s Signature:_________________________________________Date: ____________________

Your Signature:_________________________________________________ Date: ________________________ This information will be shared with our Child Health Department and members of the Primary Healthcare Team. If you do NOT want this information to be shared please tick here:


For Office use only

ANY CHILD WITH A “YES” TO ANY OF THE QUESTIONS ASKED except allergies NEEDS TO HAVE A ROUTINE APPOINTMENT WITH A DOCTOR BOOKED AT REGISTRATION

Has the child been offered appointment with doctor?

Yes No

If appointment booked please add a comment to the appointment slot stating the reason for the appointment as per the pre-registration form.

Red Book Submitted and photocopy to nurse?

Yes No

Has the identity and address been checked? Documents accepted (only one required). Tick which one: Child benefit form NHS card For those who do not have any of documents above Passport

Yes No Yes No Yes No Yes No

Has Parental Responsibility been established? Documents accepted (only one required). Tick which one: Birth certificate Red book If neither of the above available or born outside the country: Passport

Yes No Yes No Yes No Yes No

Please state who has parental responsibility:

Who checked the form? Date:

Dr John C Little MB BS Dr Jane E Harpur MB BS MRCGP€¦ · V6 Complete under 18’s registration...

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